FREDERIC W. HA FFERTY PH.D.

PROFESSOR OF M EDICA L EDUCA TION M A YO CLINIC

Working With [and within]

Medicine’s Hidden Curriculum

February 12, 2014

Medical Education Grand Rounds

University of Virginia School of Medicine

hafferty.frederic@mayo.edu

Program in Professionalism and Ethics

DISCLOSURE

Relevant Financial Relationship(s)

None

Off Label Usage

None

Objective for Today

How might we reflect differently about the structure, process and content of

medical education?

Topics for Today

What is the HC? How do we think about it? How might we biopsy it?

Some Framing Principles

U.S. Congressman Tip O’Neil Speaker of the House 1978-1987

All politics is local

All solutions to the HC are particular

Joe’s Story

Bloom, Samuel W. 1988. Structure and Ideology in Medical Education: an Analysis of Resistance to Change. Journal of Health and Social Behavior 29 294-306.

Bloom, Samuel W. 1989. The Medical School as a Social Organization: The Sources of Resistance to Change. Medical Education 23 (3): 228-41.

Bloom, SW. 1995. Reform Without Change: Look Beyond the Curriculum. American Journal of Public Health 85 (7): 907-08.

Next Generation Curriculum

system-based learning experience

Integration

“Not all of what is taught during medical training is captured in course catalogs,

class syllabi, lecture, notes and handouts…. Indeed, a great deal of what is taught—and most of what is

learned—in medical school takes place not within formal course offerings but

within medicine’s ‘hidden curriculum.’”

Shibboleths

Shibboleth: a word, sound, or custom that a person unfamiliar with its significance may not pronounce or perform correctly relative to those who are familiar with it.

It is used to identify “outsiders” or those who do not

belong to a particular group. It particularly refers to features of language, and particularly to a word or phrase whose pronunciation identifies a speaker as belonging to a particular group.

ˈhaːvəd

Rachel Prentice: Bodies in Formation

“From first case presentations to learning when to operate and when not, surgical

internships, residencies, and fellowships are grueling tests of a trainee's stamina,

fortitude, and ability to navigate the social and organizational demands of

hierarchically organized hospital work, demands that often are poorly spelled out or

require setting and revising priorities.

There is no syllabus, but residents teach each other a great deal during lessons tacked onto

the end of a surgery or during informal "corridor talk," moments when unspoken social knowledge that never ends up on

lesson plans gets conveyed.”

The Formal versus

The Other-Than-Formal Aspects

Of Everyday Life

The Problem

The Problem

The Problem

The Problem

The Solution: Informal Norms

More Solutions

More Solutions

Upon Solutions

Upon Solutions

Upon Group Solutions

A Little Humor

The King – of Parking Space Savors

Definitions

One Definitional Framing

“…a set of influences that function at the level of organizational structure and culture and whose social and cultural influences relate to the context and environment in which learning takes place.”

David Hirsh: Unpublished Manuscript 2010

Another…

“the set of influences that function at the level of organisational structure and culture including, for example, implicit rules to survive the institution such as customs, rituals, and taken for granted aspects”

Lempp, H., & Seale, C. (2004). BMJ, 329, 770-773.

From Definitions to Metaphors

Metaphors have a way of holding the most truth in the least space. ~ Orson Card

Iceberg

The HC as Dark Matter

The Babe Direct Versus Indirect Vision

Key Points

Key Points

Teaching ≠ Learning

Key Points

Context Matters

Key Points

Systems Matter

Key Points

Relationships Interconnections

Interdependencies

Key Points

Educational Settings are:

Multidimensional Relational Dynamic Complex

And thus loaded with tensions and contradictions

Key Points

Altercastings

Reframings

Key Points

Heuristic Device

Key Points

It’s not always negative

Key Points

It’s better framed as a plural

[Curricula versus curriculum]

The Student as Detective

TO SUMMERIZE

Cognitive Neurosciences Linguistics

Physics Organizational Life

Index Card Exercise #1

How much of learning takes place within the

hidden curriculum relative to the formal?

Exercise #2 An Insider’s Guide

54%

70%

How Do We Tap Into/Biopsy the Hidden

Curriculum?

Analysis of narratives about student or faculty life Discourse analysis Surveys C3 [patient-centered care]

Social Network analysis

Looking at the HC from an Organizational Sciences Perspective

Another Approach

Naheed Dosani’s Top 10 HC List

10. YOU NEED TO HAVE CHOSEN YOUR RESIDENCY PROGRAM BY THE FIRST DAY OF MEDICAL SCHOOL.

8. THE BEST WAY TO GET AN ELECTIVE IS TO CIRCUMVENT THE

SYSTEM. 7. “DUDE, MEDICAL SCHOOL IS NOT ABOUT WHAT YOU KNOW. IT

IS TOTALLY ABOUT WHO YOU KNOW.” 6. DESPITE ALL THE LECTURES ABOUT SELF-CARE, YOU STILL

HAVE TO DO 1 IN 2 CALL TO MATCH TO A COMPETITIVE SPECIALTY.

4. THE BEST WAY TO IMPRESS A PRECEPTOR IS TO MASTER “THE

ART OF PIMPING.”

Social Network Analysis

Questions? Suggestions? Criticism?